WM0501549_Application_20230503

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY- DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
1. Date: 5/2/2023
2. County: Johnston PERMIT NO. ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): monitoring
4. Applicant: Tony Southerland Telephone: [phone]
Applicant's Mailing Address: 1105 Southerland Rd Clayton, NC 27527
Applicant's Email Address (if available):
5. Contact Person (if different than Applicant): Ryan Kerins Telephone: [phone]
Contact Person's Mailing Address: 100 E. Ruffin St Mebane, NC 27302
Contact Person's Email Address(if available): rdkerins(a�terraguestpc.com
6. Property Owner(if different than Applicant): Telephone:
Property Owner's Mailing Address:
Property Owner's Email Address(if available):
7. Property Physical Address(Including PIN Number) 4549 Wilsons Mills Rd PIN#169609-07-9370
City Smithfield County Johnston Zip Code 27577
8. Reason for Well(s): groundwater contamination
(ex: non-discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
9. Type of facility or site for which the well(s)is(are)needed: UST
(ex: non-discharge facility,waste disposal site, landfill, UST,etc.)
10. Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
NCDWM-UST Incident 29463
11. Type of contaminants being monitored or recovered: petroleum
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 8
Existing Monitoring or Recovery Well Construction Permit No(s).: Unknown
13. Distance from proposed well(s)to nearest known waste or pollution source (in feet): 0-30'
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): 299
15. Well Contractor: Wes Sorrells Terraquest Environmental Certification No.: 3577
Well Contractor Address: 100 E Ruffin St Mebane, NC 27302
PROPOSED WELL CONSTRUCTION INFORMATION
1. As required by 15A NCAC 02C .0105(f)(7),attach a well construction diagram of each well showing the following:
a. Borehole and well diameter e. Type of casing material and thickness
b. Estimated well depth f. Grout horizons
C. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s)be secured?
material: 3 Bolted manhole with locked well cap
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 5/2023_
4. Total Number of wells to be constructed: 3 7. Estimated construction completion date: 5/2023
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
a. All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections,streams, or lakes within 500 feet of the proposed well or well system.
b. All existing wells, identified by type of use,within 500 feet of the proposed well or well system.
C. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.10B(5), landfills, or other waste disposal areas)within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant assumes total responsibility for ensuring that the well(s)will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Project Manger
Signature of Applicant or*Agent Title of Applicant or*Agent
Ryan Kerins *If signing as Agent, attach authorization agreement stating
Printed name of Applicant or*Agent that you have the authority to act as the Agent.
If the property is owned by someone other than the Applicant, the property owner hereby consents to allow the Applicant to construct
well(s)as outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s)will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
Signature of Property Owner(if different than Applicant) Printed name of Property Owner(if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources' Regional Office:
Asheville Regional Office Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [phone] Fax: [phone]
Fayetteville Regional Office Washington Regional Office Winston-Salem Regional Office
225 Green Street, Suite 714 943 Washington Square Mall 450 W. Hanes Mill Road
Fayetteville, NC 28301-5094 Washington, NC 27889 Suite 300
Phone: [phone] Phone: [phone] Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville Regional Office
Win to sale
610 East Center Avenue c
Mooresville, NC 28115 /LC allPhone: [phone]
Fax: [phone] 1 t
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Table 1 SITE HISTORY(USTlAST SYSTEM INFORMATION)
Date: 117109 Incident Name_ J.D's Country Store Incident No.29463 Facility ID No: 0-013454 1
- Capacity
T4 - UST Product (Gallons) Date Installed Date Closed Release Discovered
T1 Gasoline 6,000 12f5/71 719/07 Yes
T1b Gasoline 3,000 1215171 7/9/07 Yes
T2 Gasoline 12,000 1/1/02 N/A No
ASTI T3 Gasoline 8,000 111/02 NIA No
T4 Diesel 5,000 1/1/02 N/A No
L1 vim T5 Gasoline 6,000 7112107 NIA NAAST2 T5b Diesel 4,000 7/12/07 N/A NfA Lj
Capacity '� d
AST3 AST Product (Gallons) Date Installed Date Closed Release Discovered
° AST1 Kerosene 550 6l01 in-use No �I Z
AST2 Off-Road Diesel 550 6/01 in-use No
AST3 Off-Road Diesel 1,000 6101 in-use No I J
AST4 Kerosene 550 1/81 6101 No
Notes_ (n
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1. Information obtained from the INC UST Database Records,onsite observations,and responsible party. O
2. No release from the other USTs orASTs has been discovered- ,
3. Installation and closure dates for the ASTs are approximate.The ASTs are owned by Stancil Oil Company. J
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0' 15' 30' 60'
L f 1" = 30'

FIGURE 2 - TYPICAL TYPE II MONITORING WELL DETAIL
8" MANHOLE COVER
0'
i
j LOCKING CAP
GENERAL INFORMATION
/ CEMENT GROUT Groundwater monitoring wells are simple 2"
diameter wells used to monitor groundwater
quality. They are constructed using Schedule 40
PVC piping and screen as shown in the diagram
to the left. Upon completion, an 8" round
8' / manhole cover is installed over the well for
' BENTONITE SEAL protection. In the event that the well is
9
installed in an area where there exists the
10' possibility that it could be damaged such as an
TOP OF SCREEN agricultural field, an aboveground or stickup
_ manhole will be used. After the manhole is set,
a small concrete pad is poured around the
manhole. Both the manhole and pad are flush
with the ground surface, except as noted, and
will not interfere with driving, mowing, foot
traffic, etc. Type II monitoring wells are used
for sampling groundwater from shallow,
unconfined aquifers. They are used to
determine the horizontal extent of contamination.
Well Driller:
Terraquest Environmental Consultants, P.C. —
Jonathan R. Grubbs #3001
GRAVEL PACK
30' -
BOTTOM OF SCREEN
BOTTOM OF BORING
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TEP4MIUest
ENVIRONMENTAL CONSULTANTS, P.C.